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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment inspection Deport Form <br /> TYPE OF ACTION El Installation d Repair 36 Month <br /> 'J. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10844113 - San Joaquin EMD 2001 025 <br /> Facility Name <br /> Power Pomp Plaza 76 <br /> Facility Address City ZIP Code <br /> 141 E Harney Lane Lodi 95240 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> SZ Service Station Maintenance. Inc S16-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, VV Sacramento.CA 95805 <br /> Service Technician Performing Inspection <br /> Randy + lkwson <br /> CantractorfTank Tester License Number <br /> 433159 <br /> 100 Number --- Expiration Date <br /> 8822029 12127l2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Man ufacturer and Test Equipment Training Certifications Exorration Date <br /> OP - 1193835 1212012025 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures used Components Inspected <br /> PEI 1200 rg_18 3 DROP TUBE <br /> 5. CERTIFICATION BY SERVICE TECHNICI N CONDUCTING INSPECTION <br /> l hereby certify that the OPi= was inspectied in accordance with California Code of <br /> Regulafions, title 23, division 3, chapter 16, section 2637.2; fhat required suppor'fing <br /> documentation is aftached, and all r'n forma tion con fain ed herein is accurate. i understand <br /> fhat fast procedures shall be ma de available upon request by the governing aufhority. <br /> Service T -cian Signature Date Total# of Pages <br /> WW2025 ' <br /> GERS = California Environmental Reporting System, ID = Identification, [CC = International Code <br /> Oouncll, OPF = Overfill Prevention Equipment <br /> Page i of 2 <br />